Exploring depression
Exploring depression

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Exploring depression

1.1 Understanding depression − key issues

The activities below will explore key issues to help you gain a broader understanding of depression.

Activity 2 Understanding depression: key issues

Timing: Allow approximately 1 hour

Listen to the podcast below and consider the questions that follow. You might wish to listen to the entire recording first and review this again thinking specifically about the questions the second time around. Alternatively, you can consider the questions as you listen to the recording the first time around. Choose whichever approach suits you best.

Download this audio clip.Audio player: BBC World Service ‘Discovery’ − Depression part 1
Skip transcript: BBC World Service ‘Discovery’ − Depression part 1

Transcript: BBC World Service ‘Discovery’ − Depression part 1

Pauline:

There were a lot of stresses everywhere. I was trying to get back in to work. Financially we were struggling. I had three children, and I were on my own.

Aaron:

I used to have a business which we ended up having to close, and that resulted in losing my employment, I lost my income and ended up losing my accommodation.

Geoff Watts:

Aaron and before him Pauline. Two people with problems, but while Pauline suffered from depression,Aaron did not. At times, not surprisingly,Aaron’s mood has become low, but outright depression, no. Some researchers think that one way of helping Pauline would be to understand Aaron.

I’m Geoff Watts and in this, and the next edition of Discovery from the BBC World ServiceI’ll be asking two different but related questions. First,the obvious one. Why do any of us get depressed? Why hasn’t natural selection rid us of this unpleasant and apparently unhelpful state of mind? Why haven’t our brains evolved in such a way that we don’t experience this extra burden of misery when confronted with real difficulties like Pauline’s? I’ll also be turning the question round. As life events able to trigger depression are so common, how come a majority of us don’t get depressed? What is the resilience that people like Aaron seem to possess? And if we could understand it, could we exploit it? But those are issues for next time. It’s the question of why depression exists that I’ll be tackling in this programme. We need to know, not least and on account of the number of people affected by it.

Professor Bill Deakin:

We think that about a fifth of the population will suffer from diagnosable symptoms of depression at some point in their lifetime.

Geoff Watts:

Bill Deakin is Professor of Psychiatry at the University of Manchester.

Professor Bill Deakin:

It seems to be increasing in frequency, and so if you look at the prevalence of depression in the population and the age of onset, the prevalence is increasing and the age of onset seems to be getting less over succeeding decades. You know, we don’t quite know why that is. I mean there’s more diagnosis of depression, and general practitioners,which is where most depression presents, are much more sensitive to detecting it. And, you know, understand much better than they used to that depression can be a manifestation, manifested in different ways and people turning up with physical symptoms, for example, in aches and pains that won’t go away and feeling generally unwell, when the real underlying problem is depression.

Pauline:

I think with each time that I’ve suffered from depression, it’s the isolation and emotionally I was very detached. I would come in and sit by my bed and cry. And when it got so bad that I didn’t want to speak to my children, that’s when I went to the doctor’s.

Geoff Watts:

Pauline reminding us how debilitating depression can be. So debilitating,in fact,that it leaves you wondering why it still exists. Why hasn’t evolution by natural selection removed this irksome trait and left us happy, happy, happy all the time? Surely we’d then be better adapted to deal with life’s difficulties, or could it be that depression has an upside, some virtue, some benefit of which we’re unaware. And could treating it, in some cases at least, have a downside? One man who studies disease, and its origins from an evolutionary point of view, indeed he practically invented the field, is Professor Randolph Nesse of the University of Michigan.

Professor Randolph Nesse:

You know,I started off interested in psychiatry in particular, and quickly realised that I was missing important things that were there in the rest of medicine. And that led me to,really, 20 years, trying to develop the field of evolutionary medicine. It turns out there are new questions that haven’t been systematically addressed. Mainly, ‘Why isn’t the body better designed?’ I mean, why do we have an appendix? Why do we all have wisdom teeth that are so problematic? Why is the birth canal so narrow? Why do we all have so much excessive pain? Why do we get so sweaty when in hot environments? Now these are questions that have two kinds of answers. One kind of answer we call approximate or mechanistic answer, how the body works, that’s most of medical research. But the perspective George Williams and I took on these questions is to try to ask, why on earth didn’t natural selection make the body better? Some things in the body are so great,like the eye and the knee joint and the heart valves, so why leave these other parts really apparently poorly done indeed?

Geoff Watts:

It also seems to show why disease is not just arbitrary failure. It makes more sense, I guess, if you look at it in evolutionary terms doesn’t it?

Professor Randolph Nesse:

It certainly does. I mean,there are aspects of disease that probably are just arbitrary failure. Cystic fibrosisresults from a mutation and that’s that. And maybe it has some adaptive significance, but I rather doubt it. And so there are different explanations for different kinds of diseases, but for every disease we really need to ask ‘What variations are there?’ and ‘Why do we have bodies that have variations that leave us vulnerable to disease?’

Geoff Watts:

When it comes to depression, evolutionary theorists have several ways of explaining its persistence. Not all of them agree with Randolph Nesse, but as we’ll hear, his views do have the advantage of being backed by some experimental evidence. I asked him why he thinks that a capacity to get depressed might be beneficial, might be adaptive. It turns out this was not a good idea.

Professor Randolph Nesse:

That’s not the right question in my mind. The question is why we have a capacity for mood.And so many people assume that all depression is abnormal, and a great majority of it is that it gets very confusing if you try to talk about the adaptive benefits of depression per se. I think the question is ‘Why on earth have mood?’ Some people don’t have much mood. They don’t get especially happy. They never get especially sad. They just go on and on, pretty even-keeled. But most of us do have uptimes and downtimes and the question is, why?

Geoff Watts:

And the answer is?

Professor Randolph Nesse:

There are times in life when investing a lot and taking a lot of risks pays off handsomely. When the crops are ripe, and a thunderstorm is brewing, you had better get out there and gather everything as fast as you can. When you have a big opportunity to be in front of your group and say things that might be useful or interesting you’d better be there and do it well. There are other times in life,unfortunately, however, when the more effort you put in the more you’re wasting effort, and the more risks you’re taking. For some of my ancestors in Norway in the middle of the winter, when there wasn’t any game to get and any time you went out you were liable to die, the best thing to do was?Nothing. And there are times like that, fewer of them in modern societies, but there certainly were times like that.

Pauline:

Having the goal of wanting a secure job, and a partner and buying a house and all that and I,just, that bout of depression really made me think,‘Well this job’s making me unhealthy and this relationship is unhealthy for me’. At the time, I thought the best thing to do was to just get out. Yes, it was.

Professor Randolph Nesse:

We’re all trying to do things throughout our lives and usually things are working. We’re gathering food and getting friends and helping our neighbours and doing things that are working. Unfortunately there are some things that we’re trying to do that just aren’t working and the more effort we put in the worse it gets. For instance, I saw a patient recently who was desperately depressed, and it turned out the problem was that this person had dedicated her life to helping her child stay off drugs and now he was addicted to heroin. And worse yet,the more she called and the more she tried to help the more he pushed her away. She was dedicating her entire life to this goal, and not making any progress whatsoever. You can readily understand why a mother couldn’t give up on a goal like this. But nonetheless it was plunging her in to a deep depression.

Geoff Watts:

So, much of natural selection is about helping us strive for evolutionary goals for survival and,as Pauline’s experience shows, the goals in our lives today shaped by our desires and the society we live in, are still powerful drivers of behaviour and emotion. Randolph Nesse’s view is that an inability to fulfil these goals is what triggers low mood. Surprising as it might seem, perhaps mild depression is in itself a way of building some sort of resilience within sufferers to help mitigate future bouts of low mood.

Professor Randolph Nesse:

Much of medicine is using medications to block normal, aversive, defensive responses such as pain, nausea, fever, vomiting and anxiety and low mood. And in most cases it’s perfectly safe, because natural selection has shaped these responses to be greater than they really need to be in the individual circumstance. This is best described as something Williams and I have talked about as the ‘smoke detector principle’. When we all put up with lots of false alarms on our smoke detectors, because we want to be absolutely sure the smoke detector goes off when there’s a fire, even though there is a constant mild annoyance when the smoke detector goes off, when we boil tea or make a piece of toast. Now, likewise, natural selection has shaped the regulation for things like fever and nausea, vomiting, pain and,I think,low mood and anxiety according to the smoke detector principle. These mechanisms are very sensitive. They go off a lot of times when they’re not needed but this is still perfectly normal, because the system has to ensure that they go off in situations when they are needed.

Geoff Watts:

So the smoke alarm principle may be one explanation for the increasing prevalence of depression. It’s an ancient biological system, far too sensitive for modern life especially in the culture which proclaims that ‘only losers quit’, even when quitting may be beneficial. Randolph Nesse and Carsten Wrosch hypothesise that low mood helps us to recognise when our ambitions are too lofty. If they’re right about this, depression is delivering a message we do well not to ignore.

Pauline:

It’s a part of me. And while the episodes have been quite negative, I do think that I’ve gained a lot of strength from it. I think it has helped me to look at the stress within my life and to seek strategies for dealing with it. So I do think it has been a great benefit to me and the balance that I’ve found just lately in my life has helped a lot. And I don’t think that would have come about so soon in my life if I hadn’t had the depression.

Geoff Watts:

So even Pauline, someone who suffered the real misery of depression,can see how it may be helpful in spurring the adoption of new goals.

End transcript: BBC World Service ‘Discovery’ − Depression part 1
BBC World Service ‘Discovery’ − Depression part 1
Interactive feature not available in single page view (see it in standard view).

In the first of two extracts on depression, broadcast in 2012 on the BBC’s ‘Discovery’ programme, Geoff Watts talks to researchers looking for clues to the origins of depression. In interviews with Professor Bill Deakin, Professor of Psychiatry at the University of Manchester, and Professor Randolph Nesse of the University of Michigan, he asks 'Why has natural selection not made us less vulnerable to psychological illness?', and questions whether depression can in some way be useful in our lives.

  1. What proportion of the population will suffer from diagnosable symptoms of depression at some point in their lifetime?

  2. Is depression on the increase in today’s society?

  3. Is depression an adaptive response? Can the capacity to become depressed be beneficial in some way?

  4. Explain the ‘smoke detector principle’ (a concept proposed by Randolph Nesse). How can this explain the increasing prevalence of depression?

Discussion

  1. About a fifth of the population, according to Professor Bill Deakin.
  2. It appears to be increasing in frequency, according to Professor Deakin – ‘the prevalence is increasing and the age of onset is getting less over succeeding decades’. Some of this may be due to more diagnoses being made, and a greater sensitivity to detecting symptoms when first presented to the family doctor (general practitioners). Professor Deakin explains that depression can be manifested in different ways and that some people who present with physical symptoms (e.g. aches and pains that won’t go away, and feeling generally unwell) may have depression as the underlying problem.
  3. Professor Randolph Nesse explains that many people assume that depression is abnormal, but the real question should be, why have we developed a 'capacity for mood'? ‘There are times in life when investing a lot and taking a lot of risks pays off handsomely’ and ‘there are other times in life, unfortunately, however, when the more effort you put in the more you’re wasting effort, and the more risks you’re taking’, and ‘there are somethings that we’re trying to do that just aren’t working’, so the more effort we put in the worse it gets. Dedicating energy towards a goal, and not making any progress can lead to depression. Geoff Watts comments that from an evolutionary perspective, natural selection has helped us to strive for goals to ensure that we survive, whereas ‘the goals in our lives today [are] shaped by our desires and the society we live in’ and these are equally powerful drivers of behaviour and emotion. The inability to fulfil these goals is, according to Randolph Nesse, what triggers low mood. Geoff Watts asks whether mild depression in itself could be a way of building some sort of resilience ‘to help mitigate future bouts of low mood’.
  4. Randolph Nesse views pain, nausea, fever, vomiting, anxiety and low mood as normal aversive, defensive responses, and that natural selection has shaped these responses to be greater than they really need to be. They are sensitive and similar to a smoke alarm in the sense that they can go off when they are not really needed (i.e. in the absence of imminent ‘real’ danger), but this is still a perfectly normal response, ‘because the system has to ensure that they go off in situations when they are needed’. So according to Nesse, we ‘put up with lots of false alarms on our smoke detectors because we want to be absolutely sure that it does go off when there is a fire’. Geoff Watts comments further that this is ‘an ancient biological system, far too sensitive for modern life especially in the culture which proclaims that "only losers quit", even when quitting may be beneficial’. Randolph Nesse’s hypothesis is that ‘low mood helps us to recognise when our ambitions are too lofty’. The experience of depression should therefore help us to reflect, reappraise our situation, learn from experience and adjust or reset our goals.

Listen to the podcast below and consider the questions that follow. You might wish to listen to the entire recording first and review this again thinking specifically about the questions the second time around. Alternatively, you can consider the questions as you listen to the recording the first time around. Choose whichever approach suits you best.

Download this audio clip.Audio player: BBC World Service ‘Discovery’ − Depression part 2
Skip transcript: BBC World Service ‘Discovery’ − Depression part 2

Transcript: BBC World Service ‘Discovery’ − Depression part 2

Geoff Watts:

Last time we heard how low mood in the form of mild depression can actually be helpful. When life in one way or another is thwarting us the experience of depression can make us rethink our goals, can encourage us to scale back our ambitions or try following a different path. This isn’t always possible of course, or at least that’s how it seems. Either way, depression can become chronic and severe and of no benefit at all. All of us face setbacks that can disrupt our lives so you might begin to wonder why we don’t all get depressed. Psychologists like Dr Rebecca Elliott of the University of Manchester speak of people who don’t succumb to these events as having ‘resilience’.

Dr Rebecca Elliott:

In the context of mental health we think of resilience as how well somebody is able to adapt and function in the face of stressful or traumatic experiences.

Geoff Watts:

Two people who face a marriage break up, one person might get depressed, the other person might not and you’d say the person who didn’t was ‘resilient’.

Dr Rebecca Elliott:

Resilient to that particular stressful event. That’s right.

Geoff Watts:

I mean it’s a very useful thing to have. Is it widely distributed in the population? I mean, are most people resilient to some degree?

Dr Rebecca Elliott:

My instinct says it’s probably one of those occasions where we’re looking at a continuum where at one end of the continuum you have people who are very vulnerable, who in the face of quite low levels of stress or even potentially no stress at all will develop a mental health problem such as depression. Whereas at the other end of the continuum you have people who, life can deal an appalling hand, they can have all sorts of terrible stressful experiences, and yet remain positive and optimistic in the face of all that stress. And my instinct says most of us are somewhere in the middle, and we all potentially have a tipping point where enough stress, enough difficulties could cause us to have at least some degree of a problem.

Geoff Watts:

If resilience sounds more like a description than an explanation that’s exactly right. And that’s why Rebecca Elliott and her colleagues at the university are running a research project designed to find out what makes some people more able to cope than others. In essence, they’re comparing the brains of people with and without resilience. Although it so far has aroused only limited interest among depression researchers, resilience has already called the attention of those who work on post-traumatic stress disorder. And some of their insights, according to Bill Deakin, Professor of Psychiatry at Manchester University, are relevant to both conditions.

Professor Bill Deakin:

The three general ideas that we are interested in, are that firstly, some people may inherently be more sensitive to rewards in the environment. So, you know, experience in pleasurable events puts us in a good mood. And some people may need less of that to be in a good mood so they’re kind of more sensitive to rewarding or reinforcing events that occur. So that’s one aspect.

And then the second is that some people seem to be more flexible in how they solve problems, you know, we call is cognitive flexibility. So some people just seem to be more flexible and adaptable and creative about how they get out of their difficulties.

And then the third aspect is the emotional part of the brain. So we know that parts of the brain, particularly the middle parts of the brain, which seems to be a sort of central station for controlling anxiety and our responses to threat, and also responses to loss actually. That some people may be more sensitive, and what sort of loss will trigger off a big emotional response.

We’re trying to find people who appear to be very resilient to adversities of life and others who have been rather sensitive, and to see the mix of those three mechanisms, pleasure sensitivity, emotional sensitivity and cognitive flexibility. How that comes together and how it might relate to genes and, you know, whether it can be changed or not as well.

Geoff Watts:

So the characteristics of a brain which is resilient might be thought of in terms of their chemistry or in terms of their wiring and those things would possibly reflect their early experiences and their genetic inheritance?

Professor Bill Deakin:

That’s right. The two continuously interact and I think most genetic influences in depression are going to be like that.

Geoff Watts:

The Manchester researchers are working on the assumption that different states of mind, including vulnerability to depression, should correlate with different patterns of activity inside the brain. To explore them they’re using the scanning technique known as functional magnetic resonance imaging or fMRI. When volunteer subjects are slid in to the vast circular electromagnets on which these machines rely, it’s possible to image the structure of their brains. And, crucially, see which areas are functioning while they perform certain tasks. As I peered through the window that separates the control room from the instrument suite where the subjects are tested, Rebecca Elliott told me what they have to do.

Dr Rebecca Elliott:

They’re doing three different tasks while they’re in the scanner. One is an emotional memory task. We give them pictures to look at which are emotionally charged. So some are happy, positive pictures, some are sad and more negative pictures, and some are neutral pictures. And firstly, we ask them to look at them and try to remember them while their brain is being scanned. And then a little later we show them some of the same pictures again and ask them whether or not they’re pictures they’ve seen before. That’s probing emotional memory, how well people remember material that has an emotional component to it.

The second task we give them is what we call an emotional ‘go/no-go’ task. And in this people see a series of words flashing on the screen and they have to either ‘go’ (i.e. press a button), or ‘no-go’ (don’t press a button), depending on the emotional content of that word. So we have some blocks where they have to go to happy words and not go to sad words. Some blocks where we reverse that.

And then the final task we do is a task looking at their responses to rewards and punishments. And we actually use a task where they either win or lose money. And we look at how the brain responds when either they gain something, they win some money or when they lose some money.

Geoff Watts:

And in each case the hypothesis that you have is that people who have higher levels of resilience will show different pictures of activity from people who have low resilience?

Dr Rebecca Elliott:

That’s right. So at one end of our continuum, the ‘vulnerable’ people, we expect to show one pattern. The ‘resilient’ people at the other end, another pattern. And both of these will differ from, if you like, the average pattern that we see from people in the middle.

Aaron:

I’m generally a happy person, a busy person. I mean everybody has sort of stressful moments, I suppose, in their life, but day-to-day I would class myself as fairly happy. There’d be something wrong with you if you were happy all the time. But no, I certainly wouldn’t consider myself as ever having an episode of depression.

Geoff Watts:

Aaron, one of the people who volunteered to take part in the Manchester study. As you’ll have guessed he’s among those chosen for their resilience.

Aaron:

I suppose from my childhood when I first realised that I was gay, and lived with that for a long time. That taught me to sort of build up, I suppose, a sort of strong defence mechanism. And I didn’t actually come out to my parents or friends until I was much older. And so I lived with that for a long time. I suppose if you’ve gone through that situation whereby something is always in the background that is sort of fairly personal and stressful, I think perhaps that has made me deal with situations in a better way later on in life. I would say that my life can get fairly stressful at times, but it doesn’t seem to affect me in the way that it perhaps affects other people. I think it’s perhaps to do with my outlook on life. I do tend to think that if there is a problem that there’s always a solution, and I, kind of, think my way out of any problems. So it’s not that I don’t sort of think about any issues that might be going on in my life, but I always think that you can find a solution to any problems.

Professor Bill Deakin:

Well, I think that’s one aspect of being resilient. Certainly being optimistic, cheerful people. Think of your friends, you know, some of them are more cheerful and optimistic. There are some that don’t turn things over. Others turn things over a lot and ruminate about things. So using those sorts of aspects of personality I think we automatically think of some people as being resilient and tough, and others as being sort of sensitive, perhaps more liable to depression.

Geoff Watts:

Most of us do manage most of the time to stave off depression. So to understand resilience you also need a better understanding of ‘normality’, hence Bill Deakin and Rebecca Elliott’s attempts to peer inside the brain, looking for differences between subjects who do show resilience to depression and those who don’t.

Dr Rebecca Elliott:

Two particular regions that previous work have suggested may be important are a region of the brain called the amygdala, which we believe is important in processing emotional information. So we know, for example, that in people who are currently experiencing depression, the amygdala is over-responding to negative information. So, if you see a picture of a sad face, and you’ve currently got depression, your amygdala responds more strongly to that sad face. Another part of the brain we’re interested in is a part of the prefrontal cortex. And the prefrontal cortex is important in our cognitive performance, and to some extent in controlling our emotions. So regions of the prefrontal cortex will tend to inhibit the functions of regions like the amygdala. And we see this imbalance in depression, and in other emotional disturbances, and our hypothesis is that we’ll see, if anything, the opposite pattern in people who are resilient. Our early data suggests that people who are more resilient are more likely to recognise happy faces and less likely to recognise sad or fearful faces. We’ve also shown that people, exactly in line with what we hypothesise, the more resilient somebody is, the better they remember positive words and positive pictures.

Geoff Watts:

In the last few decades more and more hopes have been pinned on neuroscience as the means by which we’ll get to grips with mental health problems. But there are those who urge caution in this approach. One such is Professor Randolph Nesse of the University of Michigan. He tries to make sense of illness including depression by studying its evolutionary origins. It was he who explained in our last programme why mild depression may be beneficial. So what does he think of a ‘neuroscientific’ approach?

Professor Randolph Nesse:

A full understanding of anything in biology requires knowing every detail of the mechanism, and also how that mechanism came to be, and how it might be useful. And I have grand hopes along with most everybody else in psychiatry who is sensible that we will find specific brain abnormalities, or I should say differences, that account for why some people are more vulnerable to depression than other people who are less vulnerable to depression. However, I do see some neuroscientists acting as if the entire solution is going to be found in finding specific brain abnormalities. And it’s been very discouraging to actually look at what we’ve discovered over the past 20 years. Is there anything that can distinguish a brain of someone who has depression from a brain of someone who does not have depression? No. Not the brain scan, not the brain cutting, not the microscopic examination, not the hormones, not the neurotransmitters. There are some differences which are good clues, important clues. But our hope that we would find something specific like we find with multiple sclerosis or something has been completely dashed. It turns out depression is not in one place or one neurotransmitter. It’s distributed in systems, and those systems aren’t there just to make us depressed because it’s a problem. They’re there because the capacity for mood is useful.

Geoff Watts:

The hope of the Manchester team is, of course, that whatever insights they glean about the nature of resilience will offer ways of improving or better targeting existing treatments to prevent depression from taking hold. They’re aiming to build on what’s already done. Professor Deakin.

Professor Bill Deakin:

I mean, we do try and promote the resilience against recurrence of depression. And a lot of psychological therapies are based around that. So there’s quite good evidence that cognitive behavioural therapy, different psychological approaches, interpersonal psychotherapy, for example, a powerful technique, is a good way of reducing the chance of having a further episode if you’ve had depression. So by having depression you’re, kind of, shown to be perhaps a vulnerable person, not a resilient person.

Better psychological approaches could be devised, and enhanced by new kinds of medication that promote learning. And the combination may be particularly powerful in preventing relapse from depression. Because once you’ve had depressive illness the chance of having another one is very substantially increased over the general population. So it’s an important issue. And so that’s where we move out of society and in to the clinical situation. People who have had depression trying to promote resilience mechanisms to stop it happening again because we know it’s a big risk.

You might be able to in the future make a sort of a neuroscientific diagnosis so you get a readout of perhaps a simplified form of a scan or some EEG. Or you might get a sort of neuroscientific profile of what the particular problem is. So, in this individual, this individual got depressed because their reward mechanisms were completely fused, and actually from the emotional processing point of view and from the cognitive flexibility point of view they’re fine. So the target of therapy has to be on sort of promoting ability to respond to reward and the target might be something else. So that would really tailor make the therapy that you would have to reduce the chance of you having a second episode of depression.

Geoff Watts:

While cautious about the concept of resilience and the methods being used to study it, he applauds the intention and in particular the attempt to compare people who do get depressed with those who don’t.

Professor Randolph Nesse:

This is one of the wonderful things that’s come from positive psychology is studying not just people who have severe problems, but the people who don’t have problems despite being exposed to very dire circumstances either early in life or in adulthood. And this is very important research. We need to know how people differ and why some people just can get through things that other people cannot.

The difficulty though, is assuming that resilience is always good. Resilience is wonderful and especially in modern life where low mood, I think, is probably less useful than it used to be. The more resilient you are, up to a point at least, the better. But I really think it’s terribly important to try to, you know, be sympathetic towards people with depression not just as people with diseases who are somehow less able, and less fit than others but with people who have advantages as well as disadvantages.

End transcript: BBC World Service ‘Discovery’ − Depression part 2
BBC World Service ‘Discovery’ − Depression part 2
Interactive feature not available in single page view (see it in standard view).

In the second of the two extracts on depression broadcast in 2012 on the BBC’s ‘Discovery’ programme, Geoff Watts meets researchers studying the brain in people who have experienced traumatic life events, and explores the reasons why some people who experience such traumatic events are vulnerable to severe depression, while others are not. In this extract he talks with Professor Bill Deakin and Dr Rebecca Elliott from the University of Manchester, and Professor Randolph Nesse of the University of Michigan.

  1. How does Dr Elliott define ‘resilience’ in the context of mental health? Are most people resilient to some degree?

  2. What three general (hypothetical) aspects to resilience does Professor Deakin describe?

  3. Professor Deakin and researchers at Manchester were ‘working on the assumption that different states of mind, including vulnerability to depression, should correlate with different patterns of activity inside the brain’. What did they expect to find?

  4. Aaron, who is featured in the podcast and has volunteered to take part in the Manchester study, demonstrates some of the characteristics described for resilience. What are these?

  5. Dr Elliott talks about the involvement of the amygdala and the prefrontal cortex in resilience. Briefly explain how these brain regions are important in processing emotional information in people who are depressed.

  6. Is it possible to ‘promote’ resilience?

  7. How does Professor Deakin see ‘neuroscientific’ diagnoses operating in the future?

  8. Does Professor Nesse support this approach? Does he offer any alternative perspectives?

Discussion

  1. Dr Elliott defines resilience as ‘how well somebody is able to adapt and function in the face of stressful or traumatic experiences’. She explains that resilience can also be viewed along a ‘continuum’ in her view, with, at one end, people who may be vulnerable and ‘who in the face of quite low levels of stress or even potentially no stress at all will develop a mental health problem such as depression’. At the other end of the continuum there are those whom ‘life can deal an appalling hand, they can have all sorts of terrible stressful experiences, and yet remain positive and optimistic in the face of all that stress’. But most people are somewhere in the middle, ‘and we all potentially have a tipping point where enough stress, enough difficulties could cause us to have at least some degree of a problem’.
  2. Professor Deakin explains that (i) firstly some people may inherently be more sensitive to rewards in the environment (experiencing pleasurable events put us in a good mood), (ii) some people may be more flexible in how they solve problems (termed cognitive flexibility; i.e. more creative in how they get out of their difficulties), and (iii) some people may be more sensitive than others in how they respond to and process emotions, how emotional responses are triggered (the brain circuitry involved in controlling anxiety, our responses to threat and to loss). Geoff Watts notes that the characteristics of resilience could therefore be thought of in terms of neural circuitry, brain chemistry, previous experiences and genetic inheritance and their interaction.
  3. Dr Elliott explains that ‘at one end of the continuum, the ‘vulnerable’ people, we expect to show one pattern. The ‘resilient’ people at the other end another pattern’ and that both should differ from the ‘average pattern for people in the middle’.
  4. Aaron says that his life can get fairly stressful at times, but that it doesn’t affect him in the way that it perhaps affects others. He thinks that this may have something to do with his outlook on life. He tends to think that if there is a problem, a solution can always be found, so he can ‘think’ his way out of problems. Optimism as well as cognitive flexibility (in problem solving, for example) are aspects to resilience that have already been discussed.
  5. Dr Elliott explains that ‘in people who are currently experiencing depression, the amygdala is over-responding to negative information. So, if you see a picture of a sad face, and you’ve currently got depression your amygdala responds more strongly to that sad face’. She notes that the prefrontal cortex ‘is important in our cognitive performance, and to some extent in controlling our emotions’, and that ‘regions of the prefrontal cortex will tend to inhibit functions of regions like the amygdala’ and this is imbalanced in depression. She refers to early data suggesting that ‘people who are more resilient are more likely to recognise happy faces and less likely to recognise sad or fearful faces’, and that ‘the more resilient somebody is, the better they remember positive words and positive pictures’.
  6. Professor Deakin points to psychological therapies that are based around this concept. Once a person has had depression, the chances that they will have a further episode are substantially increased over that for the general population. Cognitive behavioural therapy, different psychological approaches and interpersonal psychotherapy are ‘a good way of reducing the chance of having a further episode’ if one has had depression.
  7. Professor Deakin sees these working more effectively as tailored to the individual. He explains this using the three aspects he referred to earlier as underlying resilience. For example, in one person, their depression could have been a consequence of ‘their reward mechanisms [being] fused’, whereas from the ‘emotional processing’ and ‘cognitive flexibility’ points of view they would be fine. In such an instance the therapy would be around promoting the ability to respond to reward.
  8. Professor Nesse is cautious of methods used to study resilience, but supportive of attempts to compare people who get depressed with those who do not. He notes the complexity of the underlying neurobiology, acknowledging that it turns out depression is not in one place or one neurotransmitter. It’s distributed in systems, and those systems aren’t there just to make us depressed because it’s a problem. They’re there because the capacity for mood is useful.’ He also points to the importance of considering people with depression ‘not just as people with diseases who are somehow less able, and less fit than others’, but as ‘people who have advantages as well as disadvantages’.

Before carrying on with the course, take 10 minutes to reflect on your learning so far.

  • Reflect on your learning in this section.

    • What were the key issues or concepts that stood out for you?

    • Can you offer further or alternative perspectives, drawing on your own personal or professional experience?

We will look more closely at diagnosis and explore depression further in Section 2.

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